BANKRUPTCY FORMS. DATE FORMS ARE TURNED IN ATTORNEY: Mark W. Ishman Date Retained:

Transcription

1 BANKRUPTCY FORMS DATE FORMS ARE TURNED IN ATTORNEY: Mark W. Ishman Date Retained: Chapter 7: Unmarried Divorced Chapter 13: (please indicate chapter filing by marking an "X") Married Widowed Unmarried person filing Married, living apart, filing jointly Married, living apart, one partner filing Ch 7 Attorney fee: FILING FEE: (Ch.7) Married living together, one partner filing Married, living together, filing jointly Ch. 13 Attorney fee: (Ch.13) Additional Fees: Consumer Credit Counseling Online Credit Report Attorney fee plus filing fee has to be paid prior to filing Office Use Only Please fill in the requested information about yourself and your spouse even if your spouse in not filing. If only one spouse is filing please indicate whether it is the husband or wife. ****INCLUDE YOUR FULL NAME, MAIDEN NAME AND/OR ANY OTHER NAMES USED.***** Please take your time filling out the forms, make sure you write legible (Male) NAME: (First) (Middle) (Last) (Female) NAME: (First) (Middle) (Last) S.S.# S.S.# ANY OTHER NAMES USED WITHIN LAST 7 YEARS: (including maiden, a/k/a, d/b/a) STREET ADDRESS MAILING ADDRESS COUNTY YOU LIVE IN: COUNTIES IN WHICH YOU OWN PROPERTY IN: PHONE NUMBERS: HOME ( ) WORK (male) ( ) WORK (female) ( ) (when calling your employment, we will be discreet) Pager/Cell ( ) (male) Pager/Cell ( ) (female) Do you have an (female) PLEASE BE SURE TO READ INSTRUCTIONS ON NEXT PAGE!!! Page 1 of 38

2 IMPORTANT! PLEASE READ AND FILL OUT THE FOLLOWING FORMS COMPLETELY, ACCURATELY AND NEATLY. YOUR FORMS CANNOT AND WILL NOT BE PROCESSED IF THEY ARE INCOMPLETE OR ILLEGIBLE. WE HAVE FOUND THAT IF WE ACCEPT INCOMPLETE FORMS, WE FIND IT DIFFICULT TO GET THE CORRECT INFORMATION. THIS IS TO ENSURE THAT WE HAVE ALL THE NECESSARY INFORMATION THAT IS REQUIRED FOR YOUR CASE. THIS IS FOR YOUR BENEFIT FOR AN ACCURATE AND SUCCESSFUL CASE. THANK YOU. Page 2 of 38

3 ISHMAN LAW FIRM, PC Mark W. Ishman, Esq. Office: (919) iphone: (919) Facsimile: (919) *INSTRUCTIONS FOR BANKRUPTCY FORMS* Enclosed is a set of paperwork that is vital for the processing of your bankruptcy. This document should be filled out completely. The most common problem we find with clients is that important information is left out. Our goal is to help each of our clients to the best of our ability, but in order to do so we need you to give complete, detailed information. Also, please do not bring your bills when you turn in forms. Listed below is information commonly left off the forms. Please make sure this information is on the forms, if the items apply to you. If you are not sure where to list a particular debt, just be sure to list it somewhere and we will sort it out Do Not Leave BLANKS! Some questions may seem repetitive, but please answer them all, put N/A in blanks that do not pertain to you. ATTACH additional sheets if necessary. You are required under penalty of perjury to list ALL Debts, including NONDISCHARGEABLE debts such as school loans and child support, and debts you intend to pay. Do not leave out property that you own or creditors that you owe. Especially if they are jointly owned or owned with spouse, family, or friend. THE INFORMATION YOU PROVIDE ON THESE FORMS MUST BE COMPLETE AND TRUE, TO THE BEST OF YOUR KNOWLEDGE. YOU WILL BE SWEARING TO THE COMPLETENESS AND ACCURACY OF THIS INFORMATION AND COULD FACE CRIMINAL PENALTIES FOR FAILURE TO DISCLOSE INFORMATION. IF YOU HAVE ANY QUESTIONS ABOUT THIS, ASK US. *When you turn in your forms, please bring the following items with you: Copy of driver s license of each party filing. Copy of your most recent pay stubs, for each party filing. (Bring Most Recent Stubs to Signing Appt.) Copy of contracts from finance companies that noted a list of your household goods (like electronics, sports equipment, etc.) for collateral. Please bring cash or a certified check for any balance remaining on the day of signing. If you are filing chapter 13, please bring proof of collision coverage on any vehicles that you still owe on and proof of homeowner s insurance if you are paying on a house or mobile home. If you are missing any pages or have any questions, please call our office. Thank you. THE ISHMAN LAW FIRM, PC Page 3 of 38

4 LIST ALL OTHER ADDRESSES, WHICH ANY PARTY FILING HAS USED IN THE LAST 3 YEARS: (List dates lived there & who lived there) If yes: PREVIOUS BANKRUPTCIES HAVE YOU FILED A BANKRUPTCY IN THE PAST 7 YEARS? of person(s) that filed: Where was it filed: Date Filed: Attorney and Phone Number: Status of Case: ANY PENDING BANKRUPTCY CASE FILED BY SPOUSE? of debtor: Date filed: Relationship: District: Judge: Page 4 of 38

5 *********************IMPORTANT******************** Do you have any money on deposit at a bank or credit union or other financial institution, where you also owe any type of debt? Yes or No If yes, be sure you are advised of the possible risks. These questions must be answered and completed or your forms will not be processed. When a client comes in for the signing appointment, all MOST RECENT paystubs must be brought in (if Applicable). Income from Employment or Operation of a Business (Before Taxes): Male Debtor s *Gross Income for all Job(s): Female Debtor s *Gross Income from all Job(s): Year to date: Gross Income for last year: Gross Income for prior year: Year to date: Gross Income for last year: Gross Income for prior year: (When we file we will need to be provided with up to date information, so please be prepared to provide that information when you sign the bankruptcy petition). ANY OTHER SOURCE OF INCOME BESIDES WORK: This includes disability benefits, workman s compensation, unemployment compensation, child support, sale of stocks, sales of residence, withdrawals from retirement accounts, etc. Male debtor: Year to date: Last year: Prior year: Source: Source: Source: Female debtor: Year to date: Last year: Prior year: Source: Source: Source: Page 5 of 38

6 The purpose of the first few pages of these forms is to obtain a complete and accurate listing of all your property. This includes all your real property, bank accounts, retirement accounts, and any debts owed to you by anybody for any reason. If any of this property has loans or liens against it, you must list the lien information following the property listing. 1. Description of residence: Value ADDRESS: (city, state & zip) TITLE OWNER(S):, Date Purchased: Amount Insured For: Purchase Price: Tax Value: of 1st mortgage holder: PAYOFF: (call creditor and get this amount, forms will not be processed w/o this information) for Lienholder (city, state & zip) Account #: Monthly Payment Are your payments behind including this month? How Far Behind? Mos. Amount Behind? Contract rate of interest: Do you want to keep OR surrender the property? Was loan received before ? yes or no Who is responsible for paying the debt? Has the debt been assigned to an attorney? If so, : : Has the creditor started foreclosure? Has hearing been set? If yes, what is date? Sale date? of 2nd mortgage holder: PAYOFF: (call creditor and get this amount, forms will not be processed w/o this information) for Lienholder (city, state & zip) Account #: Monthly Payment Are your payments behind including this month? How Far Behind? Mos. Amount Behind? Contract rate of interest: Do you want to keep OR surrender the property? Was loan received before ? yes or no Who is responsible for paying the debt? Has the debt been assigned to an attorney? If so, : : Has the creditor started foreclosure? Has hearing been set? If yes, what is date? Sale date? Page 6 of 38

7 If there are other liens on the property, please note on separate sheet of paper. Description of other real property owned: Value ADDRESS: (city, state& zip). TITLE OWNER(S):, Date Purchased: Amount Insured For: Purchase Price: Tax Value: of 1st mortgage holder: PAYOFF: (call creditor and get this amount, forms will not be processed w/o this information) for Lienholder (city, state & zip) Account #: Monthly Payment Are your payments behind including this month? How Far Behind? Mos. Amount Behind? Contract rate of interest: Do you want to keep OR surrender the property? Was loan received before ? yes or no Who is responsible for paying the debt? Has the debt been assigned to an attorney? If so, : : Has the creditor started foreclosure? Has hearing been set? If yes, what is date? Sale date? of 2nd mortgage holder: PAYOFF: (call creditor and get this amount, forms will not be processed w/o this information) for Lienholder (city, state & zip) Account #: Monthly Payment Are your payments behind including this month? How Far Behind? Mos. Amount Behind? Contract rate of interest: Do you want to keep OR surrender the property? Was loan received before ? yes or no Who is responsible for paying the debt? Has the debt been assigned to an attorney? If so, : : Has the creditor started foreclosure? Has hearing been set? If yes, what is date? Sale date? Page 7 of 38

8 BURIAL PLOTS: # of Plots & location Owners: Value: Amount you still owe: TIMESHARES: Location: Lienholder: : (city, state & zip) Value of Property: Which week(s) do you own? (What could you sell it for) Account #: Monthly Payment Payoff Are your payments behind including this month? How Far Behind? Mos. Amount Behind? Contract rate of interest: Do you want to keep it OR surrender it? (circle one) MOBILE HOMES: Description: Year Make Model Dimensions Value TITLE OWNER(S):, Lienholder: PAY OFF: (Call creditor and get this amount, forms will not be processed w/o this information) for Lienholder (city, state & zip) Account #: Monthly Payment Payoff Are your payments behind including this month? How Far Behind? Mos. Amount Behind? Contract rate of interest: Amount Behind? Contract rate of interest: Do you want to keep it OR surrender it? (circle one) Who is legally responsible for paying the debt? Page 8 of 38

9 VEHICLES, MOTORCYCLES, BOATS, CAMPERS, RV S, 4 WHEELERS, JET SKIS, OR WAVERUNNERS: Description: Year Make Model Number of Doors Mileage Value of Vehicle: Special Features or Options: Property damage or mechanical repair needed? TITLE OWNER(S):, VIN # 1ST Lienholder: PAYOFF: (call creditor and get this amount, forms will not be processed w/o this information) for Lienholder (city, state & zip) Account #: Monthly Payment First payment due date: How many months did you finance: Are your payments behind including this month? How Far Behind? Mos. Amount Behind? Contract rate of interest: Do you want to keep OR surrender the property? Who is responsible for paying the debt? Description: Year Make Model Number of Doors Mileage Value of Vehicle: Special Features or Options: Property damage or mechanical repair needed? TITLE OWNER(S):, VIN # 1ST Lienholder: PAYOFF: (call creditor and get this amount, forms will not be processed w/o this information) for Lienholder (city, state & zip) Account #: Monthly Payment First payment due date: How many months did you finance: Are your payments behind including this month? How Far Behind? Mos. Amount Behind? Contract rate of interest: Do you want to keep OR surrender the property? Who is responsible for paying the debt? Page 9 of 38

10 CONTINUED: VEHICLES, MOTORCYCLES, BOATS, CAMPERS, RV S, 4 WHEELERS, JET SKIS, OR WAVERUNNERS: Description: Year Make Model Number of Doors Mileage Value of Vehicle: Special Features or Options: Property damage or mechanical repair needed? TITLE OWNER(S):, VIN # 1ST Lienholder: PAYOFF: (call creditor and get this amount, forms will not be processed w/o this information) for Lienholder (city, state & zip) Account #: Monthly Payment First payment due date: How many months did you finance: Are your payments behind including this month? How Far Behind? Mos. Amount Behind? Contract rate of interest: Do you want to keep OR surrender the property? Who is responsible for paying the debt? Description: Year Make Model Number of Doors Mileage Value of Vehicle: Special Features or Options: Property damage or mechanical repair needed? TITLE OWNER(S):, VIN # 1ST Lienholder: PAYOFF: (call creditor and get this amount, forms will not be processed w/o this information) for Lienholder (city, state & zip) Account #: Monthly Payment First payment due date: How many months did you finance: Are your payments behind including this month? How Far Behind? Mos. Amount Behind? Contract rate of interest: Do you want to keep OR surrender the property? Who is responsible for paying the debt? Page 10 of 38

11 HOUSEHOLD GOODS The values should be the amount you estimate you could SELL the item for at a garage sale or at an auction NOT the amount you paid for the item: Kitchen Appliances Stove Refrigerator Freezer Washer Dryer China Silver Living Room Furniture Den Furniture Bedroom Furniture Dining Room Furniture Lawn Furniture Television(s) Other Video Equipment Stereo Equipment Radio(s) Other Audio Equipment Piano Organ Air Conditioner Other Household Goods, Supplies and Furnishings TOTAL BOOKS, ART OBJECTS, AND COLLECTIONS Books Paintings/Art Objects Stamp Collections Coin Collections Other Collections TOTAL CLOTHING AND PERSONAL EFFECTS Clothing Jewelry Musical Instruments Firearms Lawnmower Other Lawn Tools Power Tools Carpentry Tools Recreational Equipment Vacuum Cleaner Computer and Accessories Animals (livestock, horses or AKC Reg. pets) Other Personal Possessions TOTAL TOTAL OF ALL THREE CATEGORIES ABOVE Page 11 of 38

12 FINANCIAL RESOURCES: List all bank accounts wholly or partly in your name. 1. Cash on hand: Bank Accounts of Bank Current Balance All s on Account 2. Checking / Savings (CIRCLE ONE) Checking / Savings (CIRCLE ONE) Checking / Savings (CIRCLE ONE) Checking / Savings (CIRCLE ONE) SECURITY DEPOSITS: NAME AMOUNT Landlord CP&L Telephone Other Utilities List the of the account or type. (example, 401K, IRA, etc.). Retirement Accounts Type of Account Balance on Account Type of Account Belongs to: male or female (CIRCLE ONE) Belongs to: male or female (CIRCLE ONE) Belongs to: male or female (CIRCLE ONE) If not IRA, Government Retirement or 401K, is retirement plan ERISA QUALIFIED? (If you do not know, ask the benefits department at your employment) Other Employee Benefit Plans (type) : Do you have any other investments? Examples are Government Bonds, Stocks, Mutual Funds, Annuities, Limited Partnerships, Partnerships, ETC. Yes or No If yes, please list the investment and the current value (How much cash you can get for it.) Description Value Page 12 of 38

13 BE SURE TO READ THIS!!!! Your assets include any money owed to you or claims you have against someone else. Examples are: claims for injuries, money you loaned that has not been repaid, back child support, tax refunds, and rights in the estate of a dead person. List any such property below. Owner (Male, female or Joint) Amount Tax Refunds: (List even if you think you won t get it for some reason) Personal Injury Other Claims for Money Owed to You If so, describe (By who? What for?) LIFE INSURANCE: We need to know if you have any life insurance that has cash surrender value. There are basically 3 kinds of life insurance: Term, Whole Life, and Universal. Term is the type of insurance where benefits are only paid upon death there is no cash value that you can borrow against or cash in during your lifetime. If your insurance is through your job, it is almost always term. IF YOU HAVE TERM INSURANCE, ALL YOU NEED TO DO IS LIST Term and the people who have the insurance (i.e., husband, wife) Yes, we have Term life Insurance: (male) (female) Whole life: This is insurance that DOES build cash value. Universal: This is a cross between term and whole life that usually has some cash surrender value. IF YOU HAVE ANY LIFE INSURANCE THAT IS NOT THROUGH YOUR WORK, AND YOU ARE NOT POSITIVE THAT IT IS TERM, CALL THE COMPANY AND ASK THEM IF YOU HAVE ANY CASH SURRENDER VALUE IN YOUR POLICY. This is not information that is usually printed on your statements, so you will have to call. If you have some cash surrender value in a life insurance policy, fill out the information below: Ins. Company (Term, Whole, or Univ.) Whose Life is Insured? Who is Beneficiary? Amt of Cash Value OTHER PHYSICAL PERSONAL PROPERTY: If you own any other personal property, not already listed. Please provide a detailed list below. Property Owner (Male, female or Joint) Value(What you could sell it for ) Page 13 of 38

14 Page 14 of 38 BUSINESS ASSETS: If you have any business assets provide a detailed list below. Property Owner (Male, female or Joint) Value(What you could sell it for )

15 PURCHASE MONEY SECURITY INTEREST DEBTS( PMSI ) PMSI debts are incurred at a particular store (appliance, furniture or electronics, usually) and maybe financed by the store or a loan company for the store. These loans are made on hard, durable goods that cost more than 100 or more. PMSI debts do not include clothing or soft goods, for example a set of tires where each tire costs less than 100. These are not debts charged on a Visa, MasterCard, American Express or Discover. (Examples of PMSI debts: Circuit City; Rooms to Go, Best Buy and similar department stores.) : : (city, state, & zip) Account #: Payoff Amount: Description of Collateral Date Purchased Purchase Price (Please list items you have purchased within the last three years) Value of collateral: Monthly Payment Are Payments Current? How Far Behind? Mos. Amount Behind? Do you want to keep OR surrender the property? Who is legally responsible for paying the debt? Has the debt been assigned to an attorney/collection? If so, : : (city, state, & zip) : : (city, state, & zip) Account #: Payoff Amount: Description of Collateral Date Purchased Purchase Price (Please list items you have purchased within the last three years) Value of collateral: Monthly Payment Are Payments Current? How Far Behind? Mos. Amount Behind? Do you want to keep OR surrender the property? Who is legally responsible for paying the debt? Has the debt been assigned to an attorney/collection? If so, : : (city, state, & zip) Page 15 of 38

16 PMSI S CONTINUED : : (city, state, & zip) Account #: Payoff Amount: Description of Collateral Date Purchased Purchase Price (Please list items you have purchased within the last three years) Value of collateral: Monthly Payment Are Payments Current? How Far Behind? Mos. Amount Behind? Do you want to keep OR surrender the property? Who is legally responsible for paying the debt? Has the debt been assigned to an attorney/collection? If so, : : (city, state, & zip) : : (city, state, & zip) Account #: Payoff Amount: Description of Collateral Date Purchased Purchase Price (Please list items you have purchased within the last three years) Value of collateral: Monthly Payment Are Payments Current? How Far Behind? Mos. Amount Behind? Do you want to keep OR surrender the property? Who is legally responsible for paying the debt? Has the debt been assigned to an attorney/collection? If so, : : (city, state, & zip) Page 16 of 38

17 NON PURCHASE MONEY SECURITY INTEREST LOANS (These loans are obtained when you go to a creditor to borrow money and they ask you about your household goods, such as televisions as collateral) YOU NEED TO PROVIDE US WITH THE CONTRACT SHOWING LIST OF HOUSEHOLD GOODS LISTED AS COLLATERAL AND MARK ON IT WHAT YOU COULD SELL THE ITEMS FOR NOW, IF YOU STILL HAVE THEM : : (city, state, & zip) Account #: Payoff Amount: Who is legally responsible for the debt? Has the debt been assigned to an attorney/collection? If so, : : (city, state, & zip) : : (city, state, & zip) Account #: Payoff Amount: Who is legally responsible for the debt? Has the debt been assigned to an attorney/collection? If so, : : (city, state, & zip) : : (city, state, & zip) Account #: Payoff Amount: Who is legally responsible for the debt? Has the debt been assigned to an attorney/collection? If so, : : (city, state, & zip) : : (city, state, & zip) Account #: Payoff Amount: Who is legally responsible for the debt? Has the debt been assigned to an attorney/collection? If so, : : (city, state, & zip) Page 17 of 38

18 TAXES (Income, Property, Self Employment, Withholding) If you owe taxes this section is very important please call the correct tax office to obtain all the requested information. If you owe for more than one year you need to attach a sheet with a breakdown of the taxes owed for each year. SOME TAXES CAN BE WIPED OUT BY THE BANKRUPTCY PROVIDING ACCURATE INFORMATION MAY SAVE YOU A GREAT DEAL OF MONEY!!! Federal Taxes Amount you owe: For what year(s): Type of Tax (Ex. Income, franchise, etc.): Has the IRS filed a Federal Tax Lien? YES OR NO Are wages being garnished to pay the debt? YES OR NO If yes, how much per month? Are there any years in which you have not filed a tax return, for any reason? If yes, please list. State Taxes: Amount you owe: For what year(s): Type of Tax (Ex. Income, franchise, etc.): Are wages being garnished? If yes, how much per month? If it is owed to a state other than North Carolina, List the state and address: County Taxes of County & : Amount you owe: For what year(s): Type of Tax: Who is liable: Are wages being garnished to pay the debt? If yes, how much per month? Please be aware, if you are going to file chapter 13 and there are any years for which you have not filed, those tax returns need to be prepared and ready to file within 30 days of filing chapter 13. Page 18 of 38

19 UNSECURED CREDITORS: 1 Examples of unsecured creditors are as follows: medical bills, business services, credit cards and Student Loans.) agency? If Yes, List the and : agency? If Yes, List the and : agency? If Yes, List the and : agency? If Yes, List the and : Page 19 of 38

20 UNSECURED CREDITORS: 2 agency? If Yes, List the and : agency? If Yes, List the and : agency? If Yes, List the and : agency? If Yes, List the and : Page 20 of 38

21 UNSECURED CREDITORS: 3 agency? If Yes, List the and : agency? If Yes, List the and : agency? If Yes, List the and : agency? If Yes, List the and : Page 21 of 38

22 UNSECURED CREDITORS: 4 agency? If Yes, List the and : agency? If Yes, List the and : agency? If Yes, List the and : agency? If Yes, List the and : Page 22 of 38

23 UNSECURED CREDITORS: 5 agency? If Yes, List the and : agency? If Yes, List the and : agency? If Yes, List the and : agency? If Yes, List the and : Page 23 of 38

24 UNSECURED CREDITORS: 6 agency? If Yes, List the and : agency? If Yes, List the and : agency? If Yes, List the and : agency? If Yes, List the and : Page 24 of 38

25 UNSECURED CREDITORS: 7 agency? If Yes, List the and : agency? If Yes, List the and : agency? If Yes, List the and : agency? If Yes, List the and : Page 25 of 38

26 UNSECURED CREDITORS: 8 agency? If Yes, List the and : agency? If Yes, List the and : agency? If Yes, List the and : agency? If Yes, List the and : Page 26 of 38

27 UNSECURED CREDITORS: 9 agency? If Yes, List the and : agency? If Yes, List the and : agency? If Yes, List the and : agency? If Yes, List the and : Page 27 of 38

28 UNSECURED CREDITORS: 10 agency? If Yes, List the and : agency? If Yes, List the and : agency? If Yes, List the and : agency? If Yes, List the and : Page 28 of 38

29 EXECUTORY CONTRACTS OR UNEXPIRED LEASES (Leased Vehicles, Gym Contracts, etc.) : : Account#: Type of Contract: Collateral, if any: : : Account#: Type of Contract: Collateral, if any: : : Account#: Type of Contract: Collateral, if any: Do you want to Continue with the Lease / Contract or terminate it? Do you want to Continue with the Lease / Contract or terminate it? Do you want to Continue with the Lease / Contract or terminate it? CO SIGNERS If anyone else is a cosigner or any of your debts or liable with you on any of your debts or liable with you on any of your debts, plan provide the information below. of Co signer: Debt co signed on: : of Co signer: Debt co signed on: : CURRENT EMPLOYMENT MALE DEBTOR: Employer's : : Position with employer: Length of time employed: FEMALE DEBTOR: Employers : : Position with employer: Length of time employed: DEPENDANT NAMES Age Relationship Page 29 of 38

30 BUDGET DO NOT INCLUDE ANY PAYROLL DEDUCTED DEBTS IN THIS SECTION (i.e., car payments, credit union loans) self employed clients will need to estimate the average monthly income and estimates for taxes. Please list all income & deductions separately for each job(s) you have. Attach additional sheet if necessary. * YOU MUST ATTACH PAY STUBBS SHOWING A TYPICAL PAY PERIOD FOR EACH PERSON FILING. ** Note: if you are married, living with your spouse, but filing alone you must list net income and frequency of paychecks for your non filing spouse. Male: Female: Pay Period: Pay Period: Monthly Bimonthly Monthly Bimonthly (twice a month) (twice a month) Weekly Bi weekly Weekly Bi weekly (Every 2 wks.) (Every 2 wks.) Gross pay per period: Gross per pay period: Net pay per period: Net per pay period: Deductions : Deductions : State taxes: State taxes: Federal taxes: Federal taxes: Social security: Social security: Medicare: Medicare: Retirement: Retirement: Medical & Dental Medical & Dental Insurance: Insurance: Any other deductions? (Specify) ex.401k loans Any other deductions? (Specify) ex.401k loans INCOME OTHER THAN WAGES OR SALARY PER MONTH Male Debtor Female Debtor If self employed, reg. income (Complete form on the next page, if self employed income applies to you) Income from rental property Interest and Dividends Social Security or other government assistance Pension or retirement Spousal support received Child support received Food Stamps Other Income (Specify) Page 30 of 38

31 BUSINESS INCOME AND EXPENDITURES Income and expenses will vary from month to month for self employed people. Please use the average (not the highest or the lowest) per month that you believe it will be in the future. of Business: Type of Business: Average monthly business income: 1. : Rent/Mortgage payment 2. : Repair/Upkeep 3. : Electricity & heating fuel 4. : Water & Sewer 5. : Telephone 6. : Security 7. : Other utilities 8. : Insurance 9. : Taxes 10. : Installment payments on equipment or vehicles 11. : Rental/lease payments 12. : Maintenance of equipment 13. : Advertising 14. : Bank service charges 15. : Interest 16. : Depreciation 17. : Office expenses 18. : Dues & publications 19. : Laundry & cleaning 20. : Supplies & publication 21. : Transportation 22. : Travel & entrainment 23. : Wages & Salaries 24. : Commissions 25. : Production costs 26. : Garbage 27. : Cell Phone(s) 28. : Other expenses 29. : 30. : 31. : TOTAL AVERAGE MONTHLY EXPENSES: MONTHLY PROFIT: (Income minus expenses) This amount should be inserted under self employment on the previous page.) Page 31 of 38

32 PERSONAL / LIVING EXPENSES: Use per month figures for everything. For example, if expense is weekly, multiply by 52, then divide by 12 to get monthly amount : Rent/Mortgage payments : Home Maintenance : Electricity/Gas : Water and Sewer : Telephone : Trash removal : Security : Cablevision : Food/Groceries/Eating out : Clothing : Laundry and dry cleaning : Medical and dental services : Transportation (gas, oil changes, etc.) : Recreation, entertainment, : Charitable contributions newspapers : Homeowner/renters insurance : Tobacco products : Life Ins.: (not deducted from payroll check) : Lot Rent : Health Ins. (not deducted from payroll check) : Homeowners Dues : Auto Ins. : Pet expenses : Property taxes (Personal/Real) : Personal Grooming : Auto installment payment : Cell Phone(s) or Beeper(s) : Other installment payments (specify) : CHILD CARE (Not deducted on Payroll) : Miscellaneous : Payment for Child Support (specify below): of child Age Relationship of child Age Relationship of child Age Relationship (per month): Payment for Alimony (to whom?) (per month): Other monthly payments for dependents. Any other monthly expenses not already listed Do you have any payments deducted or automatically taken from your pay check? If yes, list name and telephone number of the creditor(s). : Phone No.: ( ) : Phone No.: ( ) : Phone No.: ( ) Page 32 of 38

33 FINANCIAL HISTORY THESE ARE VERY IMPORTANT QUESTIONS. DO NOT SKIP THEM!!!!!!!!!!!!!!!! 1(a). List payment to each creditor including the regular monthly payments on your mortgages and vehicle loans, to whom have you paid more than total within the last 100 days. For example: 200 per month for 3 months. List the following information. of Date(s) of Payment Amount (If there are more than two, please attach additional sheets with the information.) 1(b). Have you made any payments on any debts to family members or to any other person with whom you have a very close relationship within the last twelve months? If yes, provide the following: and of person: Relationship: Amount of debt? Dates of Payments Amounts of Payments 1(c). Within the last twelve months, have you made payments on any debts in which the debt is in someone else s name? Yes or No If so, list the details of the payments (If you are filing a joint case, you do not need to list payments on each other s debts.) 2(a). Have you been involved ANY lawsuits suits within the last twelve months? (This includes you suing someone else or someone suing you. It also includes divorces.) of parties involved in the lawsuit: County where case was filed: Date it was filed: Outcome: of parties involved in the lawsuit: County where case was filed: Date it was filed: Outcome: Page 33 of 38

34 2(b). Have there been any attachments or garnishments on your property or your pay within the last twelve months? of party receiving the money: Why is money being garnished (Ex. child support): How much per month: How much is the total debt: Date(s) of Garnishment: 3. Has anything belonging to you been repossessed, returned, or foreclosed upon within the last twelve months? of party who repossessed the property: Description and Value of property: Date of foreclosure or repossession: 4. Has any of your property been assigned for the benefit of creditors within the last 180 days or has any of your property been under the control of a custodian or court appointed official within the last twelve months? Yes or No 5. Have you given any gifts or charitable contributions (including church contributions) totaling more than within the last year? and address of person or organization: Relationship to Debtor, If any: Date of Gift: Description and Value of Gift: 6. Have you suffered any loss due to theft, flood, accidents, or gambling within the last twelve months? Description of property: Value: Date of Loss: Was it covered by insurance in whole or part? Give details: 7. Have you paid anyone other than this law firm to aid you with debt counseling within the last year? of Firm and Date of Payment Amt of Fee Description of Service Page 34 of 38

35 8. Have you sold or given away any property or personal belongings within the last twelve months? If, so: Date of Transfer Receiver & Description Value 9. List any and all bank accounts, certificates of deposit, or other accounts that your name was on that have closed within the last twelve months? and of Bank: Type of Account: Final Balance: Date of Closing: 10. Do you have a safe deposit box or have you closed a safe deposit box within the last twelve months? and of Bank or Depository: and of those who have access to the box: Description of Contents: Date of Transfer or Surrender (if any): 11(a). Has a tax refund been withheld from you because you owed prior taxes or child support in the last 90 days? If yes, give amount and dates: 11(b) In the last 90 days, has any bank taken money from your checking account because you owed them a debt? If yes give amount and date? 12. Are you using or holding anything that belongs to someone else? (Example: vehicle, furniture, tools, etc.) and of Owner: Description and Value of Property Held: Location of Property: 13. Have you been an Officer, Director, Shareholder, or owner of any type of business within the last six years? of Business: : Dates of Operation: Nature of interest: Tax ID #: ** If you own a business or substantial share of a business, attach a separate sheet of paper listing all assets and debts belonging to the business. You will need to indicate whether or not you have personally guaranteed the debt.** 14. List any bookkeepers and/or accountants who kept or handled your business financial books or records within the last six years. : : Explain this person's duties with regard to your books and records: Page 35 of 38

36 15. Have you or anyone else ever taken an inventory of your business property? of person in possession of inventory: : Are you in possession of the inventory? Yes or No Date of Inventory: 16. In the last six years, have you or your spouse lived outside the state of NC? If so, what states? 17. In the last six years, have you owned any real property which had any environmental problems? If so, please explain. 18. DO YOU HAVE ANY DRAFTS {AUTOMATIC DEBIT WITHDRAWAL(s)} FROM CURRENT BANK ACCOUNTS? IF YES: IT IS VERY IMPORTANT THAT OUR OFFICE BE MADE AWARE, SO WE CAN TAKE APPROPRIATE ACTION CONCERNING THESE DEDUCTIONS. LIST DETAILS BELOW: Page 36 of 38

37 * I hereby certify that I have filled out and/or provided all of the information contained in the preceding forms and that this information is true and correct to the best of my knowledge. I further certify that, to the best of my knowledge, I have not left out anyone that I owe money to, nor have I left out any property that I have any interest in. * I UNDERSTAND THAT FAILURE TO LIST ALL OF MY DEBTS AND ASSETS, OR FAILURE TO PROVIDE COMPLETE AND TRUTHFUL ANSWERS TO THE QUESTIONS IN THESE FORMS MAY SUBJECT ME TO CRIMINAL PENALTIES IN THE FUTURE. Debtor Debtor Date: Date: Page 37 of 38

38 INFORMATION UPDATE FORM BECAUSE THE FOLLOWING INFORMATION MAY CHANGE FROM THE DATE YOU ORIGINALLY TURNED IN YOUR FORMS TO THE DATE YOU ACTUALLY SIGN YOUR PETITION, PLEASE KEEP THIS FORM, FILL IT OUT COMPLETELY AND BRING IT WITH YOU TO THE SIGNING OF YOUR BANKRUPTCY PETITION. Male debtor s year to date income from all jobs: Female debtor s year to date income from all jobs: Male debtor s year to date income from sources other than jobs: Female debtor s year to date income from sources other than jobs: Balances in Bank Account: Account Balance Payoffs on Secured debts: Secured Current Payoff Payments on debts since you completed the forms: Except regular payments on mortgages and car loans. You do not need to list payment of regular monthly expenses such as: utility bills, car insurance, etc. Date Payment Page 38 of 38